Goldilocks and the 3 Bears story...with Insulin

[ClaudnDaye]

Our Endo reset Liam’s Basal program when we first joined the new team complaining that we had too many of them (10…maybe more) and started us …with a clean slate. After 3 visits, we’re pleased with our direction/A1C and how the program is morphing into something that seems to be working (but the WHY it’s working isn’t so much about the Endo and more about you all.)

So on to the story…

Once upon a time there was a boy named Liam who had Type 1 Diabetes and was using the Omnipod pump. He had a really great A1C but his new Endo made his mom and dad get rid of their old bolus and basal program because it was…too stressful, hectic and at some places made no sense (his dad recognizes that.)

Liam’s mom and dad worked hard to refine his new basal programs over the next months while working with the Endo team and the wonderful people at FUD and brought his A1C down to 6.9 at the last visit (currently 6.4). But Liam still had constant problems during the night!

His mom and dad couldn’t “turn off” the basal at nights because Liam’s BG’s would skyrocket. They tried .05, but that also caused high BG’s. When they tried .10 Liam was low most of the night. So, recently they began experimenting with different configurations of .05 and .10 through the night to see if ANYTHING would work. They tried alternating between .05 and .10 every two hours, but that still resulted in quite a few lows during the night. Then, last night, mom and dad changed it such that it alternated every 3 hours during the night. The first 2 hours were set to .05, and the 3rd hour was set to .10. The next 2 hours .05 and the next .10, etc., etc., This regimen ran from 12 midnight all the way to 11AM this morning.

The result? Liam stayed between 100 and 140 most of the night with just a couple steeper rises.

Liams parents were overjoyed to have found a regimen that works during the night. And, at the end of it all, we now have 10 basal programs again. This time; however, we have the explanation ready for our Endo and we’ll refuse to change anything because it works (well, it worked one night…we’re hoping that wasn’t a fluke, but we’ll see tonight.)

The moral of the story is: Never be afraid to experiment with things in an attempt to produce the results you need, never be afraid of “too many” basal programs, and lastly…sometimes the basal program is too small, sometimes it’s too big, and sometimes it juuuuuuuuuust right (this is the one that’s hard to find in a toddler during the nights…it’s the rare unicorn among basal program settings.)

The end.

[Eric]

@ClaudnDaye

sometimes the basal program is too small, sometimes it’s too big, and sometimes it juuuuuuuuuust right

Erin = Mama bear
Harold = Daddy Bear
Liam = baby bear

The basal program I am currently using has 13 settings in it. Whatever you need, you need!

BTW, you can tell your Endo, his pancreas adjusts every few minutes, so he can quit hassling you about your 10 settings.
http://ajpendo.physiology.org/content/ajpendo/282/3/E695.full.pdf

[Chris]

Harold, I am so glad that you found a solution for your night-time lows, and I am sure that your endo team will be impressed by the results, and not so worried about the solution, since what you have done is work around the technology to deliver a night-time basal of 0.067 u/hr which sounds like it is just right!

Finally, I have to say that your story reminds me so much of how “hard” it is to find the easy solutions to the problem. Sometimes with this disease, you beat yourself silly looking for the solution, get frustrated when nothing works, take a breather and approach it from a different direction and then “voila” you find it, and it makes perfect sense.

My fingers are crossed that he stays stable in this pattern for quite a while.

[Boerenkool]

@Eric

The basal program I am currently using has 13 settings in it. Whatever you need, you need!

BTW, you can tell your Endo, his pancreas adjusts every few minutes, so he can quit hassling you about your 10 settings.

http://ajpendo.physiology.org/content/ajpendo/282/3/E695.full.pdf

In this particular case it’s probably right to have so many settings, because the pump doesn’t allow to dose in smaller increments. However, I don’t think the endo is wrong in general. On this issue I tend to agree with this endo (or most endos and CDEs?). Yes, a pancreas adjust every few minutes, but it does so in response to blood glucose levels. Unlike an insulin pump, it doesn’t follow a preprogrammed pattern of basal rates.

This is what Stephen Ponder writes about having many basal rates and I think it makes sense:

“You see, my parallax view is that basal insulin needs are not easy to predict in advance. The human body is too dynamic. A minimal number of rates combined with good Sugar Surfing technique, mimicking the human body, is superior to an unchanging daily procession of shifting programmed basal rates. This idea is challenging to many. It would have challenged me a few years ago and I would have clung dearly to my biases. But that has changed.”
[emphasis added]
http://www.sugarsurfing.com/single-post/2017/06/24/The-Basal-Rate-Parallax

[Eric]

@Boerenkool

This is what Stephen Ponder writes about having many basal rates and I think it makes sense:

Some of Ponder’s ideas are silly:

When possible, I aim to reduce, not increase, the number of rates. If I start them on pump therapy, it’s almost always a single rate at the beginning.

If you are going to do that, you might as well use Tresiba, Stephen!

[Boerenkool]

Okay, but why is the part that I quoted silly?

[ClaudnDaye]

@Boerenkool

This is what Stephen Ponder writes about having many basal rates and I think it makes sense:

“You see, my parallax view is that basal insulin needs are not easy to predict in advance. The human body is too dynamic. A minimal number of rates combined with good Sugar Surfing technique, mimicking the human body, is superior to an unchanging daily procession of shifting programmed basal rates. This idea is challenging to many. It would have challenged me a few years ago and I would have clung dearly to my biases. But that has changed.”

[emphasis added]

http://www.sugarsurfing.com/single-post/2017/06/24/The-Basal-Rate-Parallax

Spoken like a true adult diabetic.

[Eric]

@Boerenkool

Okay, but why is the part that I quoted silly?

@Ponder

“You see, my parallax view is that basal insulin needs are not easy to predict in advance. The human body is too dynamic. A minimal number of rates combined with good Sugar Surfing technique, mimicking the human body, is superior to an unchanging daily procession of shifting programmed basal rates. This idea is challenging to many. It would have challenged me a few years ago and I would have clung dearly to my biases. But that has changed.”

You can’t necessarily predict your basal needs every day. But you sure as heck can be a lot closer if you know you need variable rates, and have them as a close approximation of the variable rates, rather than if you know you have variable rates but still leave all your basal setting as flat throughout the day, and then have to chase your BG with insulin or carbs all the time.

I have been doing this long enough, with enough different basal insulins, dosing at different times, and testing at different times to know I need more at night. And I know the difference between food’s effect and basal.

There just isn’t anyway around that. My needs may change from day-to-day, but at least I am closer by starting with variable rates I have programmed.

Ponder says it is difficult to manage different basal rates. Why?! That’s dumb. It isn’t harder to manage multiple rates. You don’t need to set them everyday. They are programmed. I can bump my basal up or down for a 1/2 hour, a single hour, for several hours, or for the entire night by just hitting an up or down %. Why is that hard to manage?

I mean, my pump doesn’t care how many rates it has. It takes the same number of button pushes for me to bump my basal up or down if I have 1 basal setting, or 20.

The problem with recommendations like his, are that they are made to the masses. Sure, not everyone may be savvy enough to know what they are doing with multiple rates. They may not understand that sometimes it is food rather than a different basal need. But rather than elevate those people, he just kind of dumbs us all down to their level. Because some people may not really understand their basal needs correctly, he just assumes none of us can handle it.

[ClaudnDaye]

@Eric

Ponder says it is difficult to manage different basal rates. Why?! That’s dumb. It isn’t harder to manage multiple rates. You don’t need to set them everyday. They are programmed. I can bump my basal up or down for a 1/2 hour, a single hour, for several hours, or for the entire night by just hitting an up or down %. Why is that hard to manage?

I will only say, that if Ponder were correct, I “should” be able to do one of three things with success. a) Turn OFF basal at nights (which produces highs); b) Set the lowest possible basal rate (.05 - which causes highs), or set the next sensible rate (.10 - which causes lows) If Ponder was correct, this would and could be the only rate that I should use. Since neither of those 3 works, to me, what Ponder says is moot. The only way to avoid lows AND highs is to do multiple basal, variable, rates.

I can understand Ponders’ comments about the difficulty in managing the basal rates, though. It is a very confusing and time-consuming undertaking to push about 20 buttons. Save. Forget about it. :: that was sarcasm, btw ::

If you don’t care about your A1C, sure…just set it up one rate and let the numbers (and your subsequent health) fall where they may. If; however, you want to accomplish 3 goals, you need variable rates (or you MAY need (and should most definitely use) multiple basal rates.)

Those 3 goals are:

• Avoid Lows as much as possible
• Avoid Highs as much as possible
• Maintain a good A1C

[Boerenkool]

@ClaudnDaye

I will only say, that if Ponder were correct, I “should” be able to do one of three things with success. a) Turn OFF basal at nights (which produces highs); b) Set the lowest possible basal rate (.05 - which causes highs), or set the next sensible rate (.10 - which causes lows) If Ponder was correct, this would and could be the only rate that I should use. Since neither of those 3 works, to me, what Ponder says is moot. The only way to avoid lows AND highs is to do multiple basal, variable, rates.

Isn’t this just a limitation of the pump that doesn’t allow you to set a basal rate of 0.07 for example?

[ClaudnDaye]

As opposed to the limitation of MDI which resulted in basal rates being way off from where they needed to be. The .05 rates allow the most finite (24 hour) management that is possible. Lantus (pens) would do nothing special during the night at all. It’s a once a day (usually we did this in the morning) shot, but the nighttime’s when we were on MDI were always above 300.

It’s a limitation period. Nothing to do with the Omnipod. MDI allows only whole units to be administered (to my recollection) . It’s just a limitation that one has to find creative ways around. Pump allows that…with multiple basal rates.

[cardamom]

Right, but I think @Boerenkool’s point was that in a perfect world, you’d be using a single basal point most likely for that time period, just at a level you can’t set the pump to. That example doesn’t represent an inherent need for variable basals so much as variable basals being used as a hack to deal with lack of adequate precision in dosing (which I agree is creative and seems like the best possible fix for the situation, and definitely way better than you could achieve with MDI, due to the tiny doses). It’s a somewhat different case though from someone who is using variable basals to attempt to match real or perceived variability in basal need.

[ClaudnDaye]

@cardamom

Right, but I think @Boerenkool’s point was that in a perfect world, you’d be using a single basal point most likely for that time period, just at a level you can’t set the pump to.

Wish we lived here! Maybe one day, we’ll be able to dose in .001 increments! Until then, people have to live in reality and do whatever they have to do to reap the best results possible.

[Thomas]

@Eric

You can’t necessarily predict your basal needs every day. But you sure as heck can be a lot closer if you know you need variable rates, and have them as a close approximation of the variable rates, rather than if you know you have variable rates but still leave all your basal setting as flat throughout the day, and then have to chase your BG with insulin or carbs all the time.

I agree.

Get the basal as close as you can then add the surfing on top of it. Hopefully smaller “surfing” adjustments.

Our basal rates have a good deal of variability throughout the 24-hr day. If the CGM shows this is appropriate then I consider that proper validation.

[Boerenkool]

@cardamom

Right, but I think @Boerenkool’s point was that in a perfect world, you’d be using a single basal point most likely for that time period, just at a level you can’t set the pump to. That example doesn’t represent an inherent need for variable basals so much as variable basals being used as a hack to deal with lack of adequate precision in dosing (which I agree is creative and seems like the best possible fix for the situation, and definitely way better than you could achieve with MDI, due to the tiny doses). It’s a somewhat different case though from someone who is using variable basals to attempt to match real or perceived variability in basal need.

Exactly, that’s my point. As I said earlier, I think that the trick @ClaudnDaye found is probably appropriate.

@Boerenkool

In this particular case it’s probably right to have so many settings, because the pump doesn’t allow to dose in smaller increments.

[Eric]

@Thomas

Our basal rates have a good deal of variability throughout the 24-hr day. If the CGM shows this is appropriate then I consider that proper validation.

My perspective is that it takes a lot of time to get the basal settings as close as you can to ideal. I wouldn’t make a bunch of changes from just one day’s results. It takes a lot of testing and time and observations. And patience.

Figuring out basal needs is one of the toughest things you have to do.

[Chris]

I don’t think Ponder is silly, just that he thinks about things differently. If he was advocating for only using a single basal long term with a pump, then I would think that is silly.

With my son we have 6 rates, and through much testing and meal skipping (on purpose and by coincidence) we know that in the absence of food my son will be flat to very slightly rising (i.e. 3-6 bg points every 1-2 hours or so). I would hate to pick one of the rates and stick with that. It is very convenient to be able to skip meals and not worry about your bg going crazy.

[Eric]

@Chris

If he was advocating for only using a single basal long term with a pump, then I would think that is silly.

That’s kind of what Ponder is saying. Ponder says “When possible, I aim to reduce, not increase, the number of rates. If I start them on pump therapy, it’s almost always a single rate at the beginning.”

I know he isn’t saying they need to stay on it single basal value forever, but it sounds like he is advocating few rates are better than multiple rates.

I think the smarter comment would not be to advocate either fewer basal rates or more basal rates, but…the correct number of basal rates. That is where I differ with Ponder’s comment.

[ClaudnDaye]

Yes, I agree. He should say something like “I recommend people use the number of basal programs (rates) necessary to help them maintain a healthy lifestyle while avoiding excessive high and low BG’s. As always YDMV so you may need more, or less basal programs than the next person.”

…instead of “I believe one size fits all. If you’re doing more (or less) programs (rates) than X number, then you are somehow doing something wrong.”

[Chris]

He may even believe that it should be the minimum number of basal rates possible, but not one.